Professional indemnity insurance Design & construct proposal form Instructions Please provide a full answer to every question. Please ensure that all answers are typewritten or printed in block letters within the spaces provided. A principal of the practice must sign and date this form and any separate sheets. 1 Name and address details Practice name (include all names under which you practice including predecessors) Main office address Telephone number Postcode: Contact e-mail address Employer s Reference Number (ERN) (found on PAYE documents) Practice website Date established List number of branch offices Please list on a separate sheet all branch offices including addresses for which you are seeking cover. 2 The firm Please advise the following (including details of sole practitioner). Name of all Partners / Directors / Members Age Qualifications Date Qualified How long as Partner / Director/ Member of the Firm(s) Please supply a curriculum vitae for any person named above who has been in this capacity for less than three years. 3 Staff Please advise number of permanent staff (excluding Partners, Directors, Members) Qualified Architects, Engineers, Surveyors 4 Activities Technical Staff All Other Staff Please provide full details of activities undertaken by your business and of any intended changes to these. (If you have a brochure detailing operations, please forward a copy) Bluefin Professions Design & construct v3.1
5 Contracts 5.1 Please provide details of the five largest contracts (in terms of total project value) undertaken in the last five years: Year Client Contract Value Total Project Value Description of your Activities Did you have responsibility for the design or other professional services? 5.2 Please provide details of the three largest contracts (in terms of total project value) expected to commence in the next 12 months: Client Your Contract Value Total Project Value Description of your Activities Will you have responsibility for the design or other professional services? 6 Turnover Please advise your turnover: Previous Financial Year Last Financial Year Estimate for the Current Financial Year Please split your turnover into the following categories: 1. 2. 3. 4. % of total where you are responsible for the design or other professional services and these activities were undertaken by your own partners, directors, members or employees % of total where you are responsible for the Construction, the design or other professional services and these activities were undertaken by professionals appointed by you or on your behalf % of total where you have no responsibility for the design or other professional services i.e. you work to the designs of, and under the supervision of, professionals appointed by the client or main contractor. % of total where you provide design and technical services only (i.e. no construction/installation is undertaken) Previous Financial Year Last Financial Year Estimate for the Current Financial Year % % % % % % % % % % % % 5. All other income, please specify % % % If income is disclosed under point 1 please provide a copy of the C.V for each partner/director/member/employee who undertakes design or other professional activities, together with a full description of the actual activities that they undertake. Financial Year End Date If any turnover is derived from work carried out in connection with any overseas contract/s, please provide full details to include countries involved and what Law/s the contract/s is/are subject to:
7 Area of practice Please specify (where applicable) the percentage of Turnover in the Last Financial Year that the following types of work represent: 7.1 HOME BUILDING a) Individual Dwellings % b) Low Rise Multiple Dwellings % c) High Rise Multiple Dwellings % d) Modular Dwellings (i.e. involving repetitive design) % 7.2 ENGINEERING CONSTRUCTION a) Highways/Roads % b) Railways, Airports, Harbours and Jetties (delete which does not apply) % c) Sewerage/Water Schemes % d) Mines & Associated Works % e) Wind Farm/Turbines (large commercial scale projects) % f) Wind Turbines (small Individual projects) % 7.3 INDUSTRIAL a) Power Plants % b) Refineries and Petro-Chemical Installations % c) Manufacturing Plants % d) Industrialised Systems Buildings % e) Bulk Handling Plant/Silos % 7.4 AMENITIES a) Hospitals and Nursing Homes % b) Schools and Universities % c) Hotels and Recreation/Leisure Centres % d) Other or Specialist Construction e.g. Swimming Pools (please provide details with % split/s if applicable):- % Total of 1-4 100% 7.5 Do you engage in the manufacture or fabrication of any pre-engineered unit? 7.6 Please add a statement of the type of work normally carried out.
8 CDM *Are you appointed or do you hold yourself out to be a Principal Designer as defined in the CDM Regulations 2015? If, please give full details including nature of services 9 Building Information Modelling contracts Are you in any way involved with Building Information Modelling contracts (BIM)? If, please give details including the level of BIM contract and any additional contractual duties being taken on by the practice. 10 Fees Please state fees paid to professionals appointed by you to undertake design or other professional services during the last year split into the following disciplines Total fees paid 1 Architectural % 2 Structural Engineering % 3 Heating & Ventilation Engineering % 4 Electrical Engineering % 5 Mechanical Engineering % 6 Civil Engineering % 7 Soil Engineering % 8 Other, please specify: - % Total of 1-8 100% Is the above split typical of the figures for the last five years? If, please give details on a separate sheet 11 Consortiums Have you ever undertaken a contract as a member of a Consortium or joint venture? If, please provide details on a separate sheet. 12 PFI / PPP projects Have you ever undertaken a contract which forms part of a PFI or PPP project? If, please provide details on a separate sheet. 13 vation / legal agreements Do you ever accept liability for professionals appointed by others by way of novation or other legal agreement? If, please provide details on a separate sheet. 14 Consultants PI Do you now, and have you in the past, always ensured that any consultants appointed by you or on your behalf hold Professional Indemnity Insurance with a limit of indemnity at least equal to that held by you? If, please provide details on a separate sheet. 15 Contract techniques / practices Do all your contracts involve well-established techniques and practices? If, please provide details on a separate sheet.
16 Claims and circumstances Has any claim ever been brought against you or any past or present director/partner/principal in connection with the performance of any design or other professional services for which you were contractually or otherwise legally responsible, or has anyone threatened to bring such a claim? If, please provide full details. Are you aware of any matters, which could lead to a claim against you? This includes: 1. Any shortcoming in your work or that of a sub-contractor, or any dispute in connection with a contract, which could lead to a claim or criminal proceedings being made against you. 2. Any criticism directly or indirectly related to design or other professional services even though regarded by you as unjustifiable. 3. Any circumstances which exist that could have a detrimental effect on your satisfactory performance of your responsibilities under a contract. If, please provide full details. (Continue on a separate sheet where necessary) 17 Previous insurance Has any insurer ever cancelled, declined, refused to renew or required an increased rate or special conditions in respect of the insurance to which this Proposal relates covering the liabilities and/or activities of any past or present Partner / Director / Member / Principal? If, please provide full details. 18 Sanctions Do you have any connection to customers or suppliers operating in the following countries or are any form of product or service sourced from or passed through these countries or indeed any employees who would visit any of these countries on business: Iran, Syria, Belarus, South Sudan, Cuba, Democratic Republic of Congo, rth Korea, Somalia, Sudan, Zimbabwe, Russia, Ukraine, Crimea. 19 Disciplinary proceedings Has any proposer / director / partner of the business: (i) Been declared insolvent or bankrupt or been the subject of bankruptcy proceedings? (ii) Been the subject of a County Court judgment (or Scottish equivalent) or are there any proceedings pending? (iii) Been a director or partner in any business which is or has been the subject of a winding up or administrative order, or receivership or other insolvency proceedings? (iv) Had a proposal form declined? (v) Had an insurance cancelled? (vi) Had special terms imposed? (vii) Been convicted or charged with any criminal offence, or have a prosecution for such an offence pending?
(viii) Been prosecuted or served with a notice of intended prosecution or a prohibition notice in connection with a breach or alleged breach of any health and safety legislation? If, please provide details: 20 Quotation requirements Please give details of the firm s current Professional Indemnity Insurance. Do not complete this question if you are already a client of Bluefin Limit of Indemnity Excess Premium Name of Insurer Renewal Date Please advise your requirements Option 1 Option 2 Option 3 Limit of Indemnity Excess People consulted in completion of the form Please list below the people you have consulted to assist with the completion of this form, including any external providers: Name Position Location Please continue on a separate sheet if necessary. Confirmation Your duty to make a fair presentation of the risk You must make a fair presentation of the risk to us when you take out, renew or amend your policy. A fair presentation requires you to tell us about all facts and circumstances which may be material to the insurance or sufficient information to put a prudent insurer on notice that further enquiries are needed, in a clear and accessible manner. Material facts are those which are likely to influence an insurer in the acceptance or assessment of the terms or pricing of your policy. If you are in any doubt as to whether a fact is material, you should tell us about it. If you fail to make a fair presentation of the risk, where that failure is deliberate or reckless, the insurer may treat your policy as if it had not existed, refuse to pay any claims and keep the premium paid. Where the failure is not deliberate or reckless but the insurer would not have accepted the policy had you told them about a material fact or circumstance, the insurer may treat your policy as if it had not existed and refuse to pay any claims but must return the premium. In other cases, the insurer may only pay part of the value of your claim or impose additional terms. For these reasons, it is important that you check all of the facts, statements and information set out in the documentation provided by us are complete and accurate, and that you answer any questions completely and accurately. If there is more than one person involved in your business or employed by you, you should check with them, where appropriate, that the facts and statements that you make are complete and accurate. If any of the facts, statements and information in this document, or any additional information provided are incomplete or inaccurate, you must contact us immediately. Failure to do so could invalidate your policy or lead to a claim not being paid. I declare that the above statements and particulars are true, full enquiry having been made, and I have not omitted, suppressed or misstated any material facts and undertake to inform the insurer of any change to any material fact. I understand that the information provided will be used by the insurer and/or their agents to arrange and administer the insurance and in handling claims which may necessitate sharing information with third parties and that information may be shared with business partners to deliver any additional services provided with this insurance. A copy of this proposal should be retained by you for your own records
This form must be signed by a principal of the firm Signature: Date: Print name: Position: Please return this application form along with any other supplementary information sheets to the address detailed below:- Bluefin Professions Castlemead Lower Castle Street Bristol BS1 3AG t: 0117 929 3344 enquiry.professions@bluefingroup.co.uk www.bluefinprofessions.co.uk Bluefin Professions is a trading name of Jelf Insurance Brokers Ltd which is authorised and regulated by the Financial Conduct Authority (FCA). t all products and services offered are regulated by the FCA. Registered in England and Wales number 0837227. Registered Office: Hillside Court, Bowling Hill, Chipping Sodbury, BS37 6JX. 2018 Jelf Insurance Brokers Ltd
Professional indemnity insurance Cladding questionnaire Instructions Please provide a full answer to every question. Please ensure that all answers are typewritten or printed in block letters within the spaces provided. A principal of the practice must sign and date this form and any separate sheets. 1 Practice details Practice name (include all names under which you practice) 2 Cladding 2.1 Have you ever taken contractual responsibility for cladding systems? 2.2 During the last 10 years have you ever been involved in a contract where external cladding was applied to a building which was in excess of 18 metres or 6 stories in height? If, please provide details below 2.3 Have you already, or do you intend to, tender for any contracts where external cladding will be applied to a building which is in excess of 18 metres or 6 stories in height? If, please provide details below 2.4 Were you, or will you be, contractually required to advise on, or be responsible for, the design, selection, specification, approval, testing, certification, inspection or installation of the cladding? If, complete 2.5 2.5 a) Was, or will, the external cladding installed be in accordance with manufactures guidelines? b) In ALL instances, has the external cladding (including components within the cladding system) used on these projects been non-combustible? If, please provide details below and complete 2.6, if, complete 2.6 2.6 In ALL instances, has the external cladding used in all projects been A2 grade, rather than FR or PE grade? If complete 2.8, if complete 2.7 2.7 List all the projects where cladding material with FR or PE grade was or is being used then complete 2.8 Name if client Type of building Address of project Contract value Start date Finish date ACM FR PE FR PE FR PE Bluefin Professions Pollution questionnaire v2.0
2.8 a) Were specialist cladding contractors engaged? b) Did these specialist cladding contractors have their own Professional Indemnity Insurance? If to a) and/or b), please provide details below and sign and date the questionnaire for return, if, to both then sign and date the questionnaire for return Declaration Your duty to make a fair presentation of the risk You must make a fair presentation of the risk to us when you take out, renew or amend your policy. A fair presentation requires you to tell us about all facts and circumstances which may be material to the insurance or sufficient information to put a prudent insurer on notice that further enquiries are needed, in a clear and accessible manner. Material facts are those which are likely to influence an insurer in the acceptance or assessment of the terms or pricing of your policy. If you are in any doubt as to whether a fact is material, you should tell us about it. If you fail to make a fair presentation of the risk, where that failure is deliberate or reckless, the insurer may treat your policy as if it had not existed and refuse to pay any claims and keep the premium paid. Where the failure is not deliberate or reckless but the insurer would not have accepted the policy had you told them about a material fact or circumstance, the insurer may treat your policy as if it had not existed and refuse to pay any claims but must return the premium. In other cases, the insurer may only pay part of the value of your claim or impose additional terms. For these reasons, it is important that you check all of the facts, statements and information set out in the documentation provided by us are complete and accurate, and that you answer any questions completely and accurately. If there is more than one person involved in your business or employed by you, you should check with them, where appropriate, that the facts and statements that you make are complete and accurate. If any of the facts, statements and information in this document, or any additional information provided are incomplete or inaccurate, you must contact us immediately. Failure to do so could invalidate your policy or lead to a claim not being paid. I declare that the above statements and particulars are true, full enquiry having been made, and I have not omitted, suppressed or misstated any material facts and undertake to inform the Insurer of any change to any material fact. I understand that the information provided will be used by the insurers and/or their agents to arrange and administer the insurance and in handling claims which may necessitate sharing information with third parties and that information may be shared with business partners to deliver any additional services provided with this insurance. A copy of this proposal should be retained by you for your own records This form must be signed by a principal of the firm Signature: Date: Print name: Position: Please return this application form along with any other supplementary information sheets to the address detailed below:- Bluefin Professions Castlemead Lower Castle Street Bristol BS1 3AG t: 0117 929 3344 enquiry.professions@bluefingroup.co.uk www.bluefinprofessions.co.uk Bluefin Professions is a trading name of Jelf Insurance Brokers Ltd which is authorised and regulated by the Financial Conduct Authority (FCA). t all products and services offered are regulated by the FCA. Registered in England and Wales number 0837227. Registered Office: Hillside Court, Bowling Hill, Chipping Sodbury, BS37 6JX. 2018 Jelf Insurance Brokers Ltd